Patients with complex care needs account for an increasingly large portion of medical expenses. In fact, individuals with complex needs account for just 5 percent of the U.S. population but account for 50 percent of all health spending.
This means everyone seeking to control costs while maintaining (or improving) quality of care must establish and support top-notch, multi-disciplinary care management teams to help this segment of the population.
It isn’t easy. Because medical complexities are usually compounded by behavioral and socioeconomic challenges, these individuals need high-touch, frequent care across medical, community and behavioral services. They need someone on their side who not only understands their needs medically, but knows them as people and gets the barriers they face.
Individuals with complex medical, social and behavioral needs are among the most vulnerable people we serve. We believe they need a strong, empathetic advocate who knows their stories, their needs and who is willing to be their voice in the system and a compassionate guide along their healthcare journey.
Engaging and, most critically, maintaining engagement requires care managers to understand and operate from the individual’s perspective. It is only from this vantage point that we can address all of their needs and develop care plans that will improve their lives. When we understand each person holistically, we can work together with them and their families to create plans they are most likely to stick with.
I’d like to introduce you to Jessica and her care manager, Melanie.
Melanie is a certified maternity case manager who has been providing nursing care for more than 37 years. Her experience spans a variety of settings including women, infant and children inpatient services, and medical surgical home healthcare services. As the proud mother of two and loving grandmother to four, Melanie understands how important her role is and shines in her ability to educate and promote healthy mom and healthy baby outcomes.
When we first met Jessica*, she was 24 years old, pregnant and living out of state with her fiancée. After an unpleasant breakup (aren’t they all?), she returned home to live with her parents and have her baby.
Her pregnancy was identified as high-risk during a routine check-up and came to the attention of Melanie, one of our care managers who specializes in high-risk pregnancies.
It would be understandable to think you had all the information you needed to help Jessica at this point. You would be wrong.
Before jumping in to develop a care plan, Melanie took the time to get to know Jessica and her parents, hear their stories and understand their current living situation, worries and fears. Melanie began by establishing herself as a trusted guide and resource for Jessica.
Through those initial conversations, Melanie learned how Jessica was distraught over the breakup, and worried about the impact on her parents. Jessica felt grateful her Asian-American culture and family welcomed her home with open arms, but without a job or viable prospects, she was worried she would be a burden. Jessica didn’t know how she was going manage her care – or her baby’s care.
Through talking with Jessica’s parents, Melanie learned they already had a grandfather living with them in their modest home and they didn’t think the baby’s father would be helping much. They were definitely worried about supporting Jessica and her baby financially. Being under 26 years of age meant Jessica could remain on her father’s employer-sponsored health plan, but they didn’t know how they would get health insurance for the baby.
These conversations gave Melanie a solid starting point and revealed the need for services that might otherwise have gone uncovered.
Thankfully, Melanie is well-versed in complex care and has a strong multi-disciplinary team supporting her. After securing Jessica’s consent, Melanie enrolled her in a program to address her social needs. Knowing she was likely eligible for state assistance in the state she moved from and the state she lived in, Melanie enlisted the help of a teammate specializing in social work. Together, they worked with Jessica to make the appropriate applications in each eligible state. They also helped Jessica apply for state-sponsored healthcare coverage for her baby.
Throughout this experience, Jessica knew Melanie was on her side and even though there was a team working to help her, all care was coordinated through Melanie, so Melanie was an effective single point of contact, which made the entire process easier for Jessica and her family.
In time, Jessica gave birth to a beautiful baby boy and, looking back at her experience, was deeply appreciative of the patience, kindness and effective help she received from Melanie.
The multi-disciplinary care team does not provide medical care. They assist individuals in getting the care they need.
This story is based on the experience of an individual receiving care from the Geneia clinical care team. The name, likeness and certain identifying details have been changed to protect privacy. This story isn’t meant to give any medical advice or recommend any specific healthcare strategy or course of treatment. If you have specific healthcare needs, or may be in need of healthcare treatment, please see a physician or healthcare professional.